Name
First Name
Last Name
Name of children (If relevant)
Address
Street Address
Street Address Line 2
Suburb
State / Province
Post Code
Phone Number
Email
example@example.com
I give Pacific Link Housing permission to use photos, videos, audio or written testimonials of myself and /or my children.
Yes
I understand that the content will belong to Pacific Link Housing and that I will not receive monetary compensation.
Yes
I give Pacific Link Housing permission to use my first name.
Yes
I understand that I can take back my consent in writing and that Pacific Link Housing will cease using the content in future publications. Note: To change your consent, please email info@pacificlink.org.au or write to PO Box 1888, Gosford NSW 2250.
Yes
I would be willing to provide testimonials / comments to associated third parties about my housing experience and support received. Note: We will not disclose your details to any third party without checking with you first.
Yes
Notes/Exclusions (Comments Box)
Print Name
Signature
Date signed
-
Day
-
Month
Year
Date
Please verify that you are human
*
Submit
Should be Empty: